Studies of the vascular anatomy of the subscapular system have dramatically expanded the versatility of this donor site and its range of applications to the head and neck. Large separated skin islands, muscle or musculocutaneous units and bone may be transferred based on one single pedicle, providing the most freedom for reconstruction of any composite defect (Figure 18-33).

The length of bone that can be harvested from the lateral border of the scapula ranges from 10 to 14 cm, depending on the sex of the patient.86 The thickness of this bone, however, is not enough to place osseointegrated dental implants and therefore it is selected only for reconstruction of mandibular defects that involve the ascending ramus and require moderate to large amounts of soft-tissue fill and skin replacement over the cheek (see related chapter). As an osseocutaneous composite flap the scapular flap also has been used to reconstruct maxillectomy and midfacial defects.86-88 The floor of the orbit or palate is reconstructed with the bony segment and one or two skin islands are used for inner lining and/or skin

Figure 18-31. In situ appearance of fibula free flap with skin island.

coverage. Potential pitfalls with the scapular flap for reconstruction of such defects include: difficulty placing the different tissue components, a short pedicle that cannot reach the neck vessels and therefore vein grafts are required, and the need to reposition the patient during surgery.

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